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2017 Oregon Dental Conference® Course Handout Shawneen Gonzalez, DDS, MS Course 8110: “CBCT in the Dental Office: Recommendations and Creating a Systematic Interpretation” Thursday, April 6 1:30 pm - 4:30 pm CBCT in the Dental Office: Recommendations and Creating a Systematic Interpretation Objectives 1. Describe the strengths and limitations of CBCT aiding in the prescription and use of CBCT scans based on academy recommendations. 2. Describe and identify common incidental findings seen on CBCT scans. 3. Create a sample CBCT written interpretation. ADA Recommendations (August 2012) Prescribing a CBCT 1. You MUST review the patient’s medical and dental history prior to prescribing a CBCT scan. 2. You MUST perform a thorough clinical examination prior to prescribing a CBCT scan. 3. You MUST show justification that the excess radiation to the patient will result in a benefit outweighing the risk. 4. CBCT scans SHOULD only be prescribed when traditional (2D) radiographs will not show the area in question. 5. CBCT scans SHOULD be prescribed by a licensed dentist with training and education in CBCT imaging. This includes staying informed with evidence based articles and continuing education courses on the use of CBCT in dentistry. Taking a CBCT scan (for offices with a CBCT machine) 1. Before a CBCT machine is installed, a health physicist SHOULD be consulted to ensure the machine is placed in an area that abides by federal regulations, state regulations and National Council on Radiation Protection & Measurements (NCRP) report 145. 2. ALARA (as low as reasonably achievable) SHOULD always be used. This means using the smallest FOV (field of view) with the shortest exposure time that will show the area in question. 3. Thyroid collars and lead aprons SHOULD be used as long as they do not interfere with the area being scanned. 4. Dental professionals using a CBCT scan MUST receive training and education about the safe use of a CBCT machine. 5. Offices with a CBCT machine SHOULD take continuing education courses on CBCT and radiation safety. 6. Offices with a CBCT machine MUST follow federal and state radiation regulations. Offices SHOULD establish a quality control program including having a health physicist evaluate the machine on a set schedule (typically determined by your state radiation regulations). Interpretation of a CBCT scan 1. CBCT scans SHOULD be evaluated by a dentist with training and education in CBCT interpretation. 2. The entire CBCT scan (or dataset) MUST be interpreted and findings entered into the patient chart. It is the responsibility of the referring dentist to relay these findings to the patient. AAOMR Recommendations (2008) The American Academy of Oral and Maxillofacial Radiology (AAOMR) has recommendations for dentists who either have a CBCT unit in their office or those who are referring a patient for a CBCT. The four recommendations are as follows. 1. The CBCT unit must be operated by either a licensed practitioner or certified radiologic operator. 2. The practitioner, referring or owner, is responsible to interpret the findings of the entire scan and generate a report of the findings. The scan may be interpreted by an oral and maxillofacial radiologist to aid the practitioner. 3. Documentation in the patients’ record must show that a clinical exam and history were obtained as well as demonstrate the need for CBCT. 4. The imaging site should use the lowest radiation dose as necessary to achieve the desired result. Anatomy and Common Incidental Findings (By Regions) Paranasal Sinuses Sinus Maxillary Sinus Key Anatomy Maxilla bone Other Infraorbital foramen and canal Zygomatic process of the maxilla Uncinate process (part of ostiomeatal unit) Sphenoid Sinus Ethmoid bone Sphenoid bone Ethmoid Air Cells Lamina papyracea Frontal Sinus Ethmoid bone Lacrimal bone Frontal bone Mastoid Air Cells Temporal bone Mastoid process (primarily) Common Incidental Findings Finding Mucous retention pseudocyst Views best visualized on Radiopaque soft tissue thickening of the sinus to complete Axial radiopacification of a sinus Coronal Sagittal Dome-shaped radiopaque mass in a sinus Coronal Sagittal Antrolith Radiopaque entity in a sinus (calcification) Sinusitis How it presents Axial Coronal Sagittal Nasal Cavity Bones that create this region Maxilla Lateral borders Forms part of nasolacrimal duct border Ethmoid Uncinate process Uncinate process is part of the ostiomeatal unit Nasal concha Superior and middle Meatus Superior and middle Perpendicular plate Perpendicular plate is part of the nasal septum Vomer Key Anatomy Other Vomer is main bony component of the nasal septum Palatine Inferior Nasal Concha Inferior meatus is drainage for nasolacrimal duct Nasal Common Incidental Findings Finding Deviated nasal septum Concha Bullosa (aerated concha) How it presents Deviation of the nasal septum Views best visualized on Axial Coronal Radiolucent center of a concha Axial Coronal Airway Airway part Nasopharynx Oropharynx Laryngopharynx Common Incidental Findings Finding Adenoidal hyperplasia Borders Soft palate (uvula) superiorly to posterior border of the nasal cavity Soft palate (uvula) inferiorly to the epiglottis Other Adenoids Tonsils Epiglottis inferiorly to cricoid cartilage How it presents Enlargement of adenoids in nasopharynx Views best visualized on Sagittal Cranial Skull Base Bones that Key Anatomy create this region Frontal Ethmoid Sphenoid Occipital Temporal Cribiform plate Crista galli Body Other Crista galli is attachment for falx cerebri Sella turcica, Clinoid processes (anterior and posterior), Clivus, Carotid sulcus which houses cavernous sinus including internal carotid artery, foramen lacerum, carotid canal Greater wings (2) Foramen rotundum, foramen ovale, foramen spinosum and vidian canal Lesser wings (2) Lesser wings include optic canal and superior orbital fissure Pterygoid processes (2) Medial and lateral pterygoid plates with hamulus projecting off the medial pterygoid process. Also creates borders for pterygomaxillary fissure and pterygopalatine fossa Posterior to foramen magnum, sigmoid sinus depression Squamous part Basilar part Anterior foramen magnum and includes the clivus of the occipital bone, jugular foramen Condylar parts Lateral borders of foramen magnum and occipital condyles, jugular foramen Foramen magnum Squamous part Zygomatic process of the temporal bone Petrous part Petrous part houses inner ear Mastoid part Mastoid process and air cells Tympanic External auditory meatus Styloid process Common Incidental Findings Finding Jugular foramen size variations EAC (external auditory canal) cerumen impaction How it presents Asymmetrical jugular foramen Views best visualized on Axial Radiopaque mass(es) in the external auditory canal Axial Coronal Sagittal Orbit Bones that create this region Frontal Key Anatomy Supra-orbital notch Other Superior aspect of orbital rim Lacrimal Lamina papyracea Medial border posterior to maxilla Maxilla Inferior and medial aspects of orbital rim Ethmoid Medial border posterior to lacrimal Zygomatic Inferior and lateral aspects of orbital rim Sphenoid Posterior aspect Common Incidental Findings Finding Trochlear apparatus calcifications How it presents Radiopaque U shaped area near supero-medial aspect of orbital contents Views best visualized on Axial Coronal Brain Brain part Anterior (anterior cranial fossa) Middle (middle cranial fossa) Borders Frontal bone Ethmoid bone Lesser wings of sphenoid bone Greater wings of sphenoid Temporal bone Posterior (posterior cranial fossa) Parietal bone Occipital bone Temporal bone Other Falx cerebri Cavernous sinus (internal carotid artery) Petroclinoid ligament Interclinoid ligament Superior aspect of petrous portion Pineal gland Vertebral artery Choroid plexus Posterior aspect of petrous portion Parietal bone Common Incidental Findings Finding Cavernous carotid artery calcifications Pineal gland calcification How it presents Curved / Linear radiopaque entities lateral to sphenoid sinus Views best visualized on Axial Coronal Radiopaque mass in midline at level just superior to the posterior clinoid process Axial Coronal Sagittal Cervical Vertebrae Cervical Vertebrae C1 (atlas) C2 (axis) C3 to C6 Common Incidental Findings Finding Degenerative Joint Disease Accessory ossicle formation Key Anatomy Anterior arch Posterior arch Foramen transversarium Body (odontoid process) Transverse process (2) Lamina (2) Spinous process Foramen transversarium Body Transverse process (2) Lamina (2) Spinous process Other Posterior ponticle How it presents Asymmetrical joint space narrowing Osteophyte formation Subchondral cyst formation Bony erosions Facet hypertrophy Views best visualized on Sagittal Axial Coronal Radiopaque mass(es) superior to dens Sagittal Soft Tissues Soft Tissues part Prevertebral soft tissue Key Anatomy / Location Anterior to cervical vertebrae Other Floor of mouth / tonsillar region Everywhere else Common Incidental Findings Finding Tonsiliths Hyoid Carotid artery How it presents Radiopaque mass(es) lateral to airway Views best visualized on Axial Coronal Sialoliths Radiopaque mass medial to body of mandible Axial Coronal Carotid artery calcification Curved / Linear radiopaque entities antero-lateral to C3/C4 Axial Coronal Sagittal Jaws Bones Maxilla Mandible Common Incidental Findings Finding Degenerative joint disease (TMJ) Focal idiopathic osteosclerosis Key Anatomy Alveolar process Other Mandibular canal Mental foramen Condyle Coronoid process How it presents Asymmetrical joint space narrowing Osteophyte formation Subchondral cyst formation Bony erosions Views best visualized on Rotated sagittal cross-sectional Rotated coronal cross-sectional Sagittal Coronal Radiopaque area with radiopacity of cortical bone Axial Coronal Sagittal Cone Beam Computed Tomography (CBCT) Radiology Report Indication: Date of Imaging: Protocol: A (( )) cone beam CT dataset of the [anterior half of the skull and cervical vertebrae] [maxilla] [mandible] was acquired and reconstructed. The resultant axial, coronal, sagittal, panoramic and orthoradial reconstructions were examined. Teeth/Jaws: Inflammation Impactions Fractures Foreign bodies TMJ: Morphology Degenerative joint changes Paranasal Sinuses: Bony borders Soft tissue thickening/opacification Nasal Cavity: Bony borders Ostiomeatal units Concha Airway: Airway patent Adenoidal hyperplasia Cranial Skull Base: Bony borders Canals and foramina Orbit: Bony borders Calcifications Pathosis Morphology Foreign bodies Nasal septum Brain: Calcifications Cervical Morphology Prevertebral soft tissue width Soft Tissues: Calcifications Interpretation/Impression: Degenerative joint changes Foreign bodies evident Ossifications/calcifications Cone Beam Computed Tomography (CBCT) Radiology Report Indication: Date of Imaging: Protocol: A (( )) cone beam CT dataset of the [anterior half of the skull and cervical vertebrae] [maxilla] [mandible] was acquired and reconstructed. The resultant axial, coronal, sagittal, panoramic and orthoradial reconstructions were examined. Teeth: Jaws: Paranasal Sinuses: Nasal Cavity: Airway: Cranial Skull Base: Orbit: Brain: Cervical Vertebrae: Soft Tissues: Interpretation / Impression: Self-test 1. Reviewing a patient’s medical history and dental history along with performing an oral exam is recommended prior to prescribing/ordering a CBCT. T/F 2. Which of the following is a common incidental finding in the nasal cavity? a. Antrolith b. Pineal gland calcification c. Concha bullosa d. Focal idiopathic osteosclerosis 3. Degenerative joint disease changes in the cervical vertebrae include: asymmetrical joint space narrowing, osteophyte formation, bony erosions, facet hypertrophy and subchondral cyst formation. T/F 4. Degenerative joint disease changes in the temporomandibular joints include: asymmetrical joint space narrowing, osteophyte formation, bony erosions, facet hypertrophy and subchondral cyst formation. T/F 5. Which of the following cannot operate a CBCT unit to capture scans in the state of Oregon? a. Dental student b. Licensed dentist c. Dental assistant with CDA d. Licensed hygienist 6. When creating a CBCT report you only need to comment on the area of concern. T/F Answer key 1. 2. 3. 4. 5. 6. T C T F A F